Simplified Setup to Achieve Distraction for Toe Arthroscopy Cody R. Englert, M.S. III, Alicia M. Unangst, M.S. IV, M.C., Kevin D. Martin, D.O., M.C.  Arthroscopy Techniques  Volume 5, Issue 4, Pages e815-e819 (August 2016) DOI: 10.1016/j.eats.2016.03.010 Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 1 The image showing our patient's left foot in the supine position with a small soft bump under the left hip. The operative heel is placed within one hand breath of the end of the table. Next, the Arthrex Trimano positioning arm is attached to the end of the operative table at approximately the same level as the operative heel; this position allows for ample distraction with gravity or manual traction. This position is adequate for most finger trap attachments while providing unimpeded access for a c-arm fluoroscopy. Arthroscopy Techniques 2016 5, e815-e819DOI: (10.1016/j.eats.2016.03.010) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 2 The image showing proper preparation of the toes for great toe metatarsalphalangeal joint arthroscopy. Toes 2 to 5 are wrapped together in a single Ioban wrap. The great toe is then separately wrapped after the surgical prep has completely dried; the Ioban should be nearly twice as long as the toe due to the fact that it will be incorporated in the distraction. Mastisol adhesive is then applied to the Ioban on the great toe followed by immediate application of an extra-large finger trap. The toe is marked to indicate the correct portal placement approximately 5 mm on either side of the extensor hallucis longus tendon. Arthroscopy Techniques 2016 5, e815-e819DOI: (10.1016/j.eats.2016.03.010) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 3 The image showing a patient in the supine position properly prepped and draped in a sterile fashion. The great toe metatarsalphalangeal joint dorsal lateral and dorsal medial portals along with the extensor hallucis longus are palpated and draw out. The external positioning arm is sterilely prepped with a specific Arthrex Trimano sheath and the great toe is prepped with Ioban followed by a large Chinese finger trap. The distal loop of the finger trap is then simply looped around the central post of the positioning arm eliminating rope/pulleys and external weights. The toe is now ready to be placed in the correct position with simple gravity or traction applied as needed. Arthroscopy Techniques 2016 5, e815-e819DOI: (10.1016/j.eats.2016.03.010) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 4 The images showing great toe metatarsalphalangeal joint arthroscopy with the patient in the supine position with soft tissue distraction to gravity. A 2.7-mm arthroscope in the dorsal medial portal looking lateral, an osteochondral lesion can be identified on the infralateral aspect of the proximal phalanx. The second image shows the microfracture of the lesion using a standard Smith and Nephew small joint 45° angle microfracture awl. Arthroscopy Techniques 2016 5, e815-e819DOI: (10.1016/j.eats.2016.03.010) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 5 The image showing a patient in the supine position with the left great toe in soft tissue distraction to gravity. A 30° 2.7-mm arthroscope is in the metatarsalphalangeal joint dorsal lateral portal looking lateral and proximal. The soft tissue band seen is the plantar plate, which has partially ruptured and flipped into the joint. Arthroscopy Techniques 2016 5, e815-e819DOI: (10.1016/j.eats.2016.03.010) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 6 The images showing a dorsal cheilectomy of the great toe metatarsalphalangeal joint. After completion of the diagnostic examination traction is released to allow dorsal capsular expansion. A 2.7-mm arthroscope is in the dorsal lateral portal and the shaver is working through the dorsal medial portal. The ridge seen at the tip of the shaver is the metatarsal dorsal osteophyte typically described with hallux rigidus. The second image shows postsynovectomy and dorsal osteophyte resection, while preserving the articular cartilage. Arthroscopy Techniques 2016 5, e815-e819DOI: (10.1016/j.eats.2016.03.010) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions